Maria G. Tanzi, PharmD
Management of patients with heart failure (HF) has evolved over the past few years, prompting the American College of Cardiology (ACC) to release an updated Expert Consensus Decision Pathway to provide guidance and recommendations on the clinical care of patients with HF with a reduced ejection fraction (HFrEF). The update focuses on 10 pivotal issues in patients with HFrEF (see sidebar).
“New therapies for HFrEF have emerged that expand the armamentarium for the treatment of patients with HFrEF,” wrote the guideline authors. “In particular, the emergence of angiotensin receptor–neprilysin inhibitors (ARNIs), sodium–glucose cotransporter-2 (SGLT2) inhibitors, and percutaneous therapy for mitral regurgitation represent significant advances in the treatment of HFrEF.”
Medication highlights
Following the publication of the previous guideline in 2017, data have emerged to support the expanded role of ARNIs in patients with HFrEF. ACC’s updated guideline notes that the ARNI sacubitril/valsartan (Entresto—Novartis) is the preferred agent, with an angiotensin-converting enzyme in-
hibitor (ACEI)/angiotensin receptor blocker (ARB) recommended for those in whom ARNI administration is not possible. The guidance states that the totality of the data supports a direct-to-ARNI approach and gives recommendations on how to initiate therapy in ACEI/ARB–naive patients or those who may be switching from an ACEI/ARB treatment to an ARNI.
To avoid the potential for angioedema, a 36-hour waiting period is required before initiating an ARNI in patients who were previously on an ACEI, the guideline states. No waiting period is needed if switching from an ARB to an ARNI. The guideline recommends that ARNIs be given in conjunction with evidence-based beta-blockers—carvedilol, metoprolol succinate, or bisoprolol—and a diuretic agent.
The guideline also discusses the emerging data with use of SGLT2 inhibitors in patients with HFrEF. Data for dapagliflozin (Farxiga—AstraZeneca) and empagliflozin (Jardiance—Boehringer Ingelheim, Lilly) show a reduced risk of major events in patients with HFrEF regardless of the presence of diabetes. These agents can be used in conjunction with guideline-directed medical therapy in patients meeting specific eGFR criteria. Ivabradine (Corlanor—Amgen) can be used as an add-on for patients with a resting heart rate of 70 or higher who are on a maximally tolerated dose of a beta-blocker and in sinus rhythm.
The importance of titrating medications is also discussed, with adjustments to treatments recommended every 2 weeks, after an HF diagnosis (as tolerated). The goal is to achieve optimal treatment doses within 3 to 6 months after the initial diagnosis. Follow-up assessments should focus on the patient’s clinical status, blood pressure measurements, and kidney function (and electrolytes).
Adherence strategies
In a section on strategies to improve adherence in patients with HFrEF, the guideline suggests simplifying the medication regimen whenever possible; considering the cost of medications and access (e.g., proactively discuss out-of-pocket costs with patients); educating using practical, patient-friendly information; and anticipating problems that may arise (e.g., communicate adverse effects, discuss when to refill prescriptions).
The guidance notes that the language has shifted from one of “compliance” to “adherence” and now to “activation,” “engagement,” and “empowerment.” It adds that the integration of pharmacists, patient navigators, and registered nurses in collaborative practice may help with optimization of guideline-directed medication therapy for patients with HFrEF.
10 pivotal issues in patients with HFrEF
- How to initiate, add, or switch therapies to new evidence-based, guideline-directed treatments
- How to achieve optimal therapy given multiple drugs for HF
- When to refer to an HF specialist
- How to address challenges in coordination of care
- How to improve medication adherence
- What is needed in specific patient cohorts (e.g., Black Americans, older adults)
- How to manage costs and access to HF medications
- How to manage increasing complexity of HF
- How to manage common comorbidities
- How to integrate palliative care and the transition into hospice care
Source: www.jacc.org/doi/pdf/10.1016/j.jacc.2020.11.022.